Online Forms

Referral Form

For dental and medical offices referring a patient — including referrals to our board-certified pediatric specialist, Dr. Julie Maniate. We'll report back after the visit.

Step 10%

Referring office

Referring doctor

This field is required.

Practice name

This field is required.

Office phone

This field is required.

Office email

This field is required.

Patient & reason for referral

Patient name

This field is required.

Patient date of birth

This field is required.

Patient phone

This field is required.

Referral for

Pediatric specialist care (Dr. Maniate) Dental implants / surgical consult Sedation dentistry General / comprehensive care Second opinion Other

Clinical notes / reason for referral

Relevant findings, urgency, and anything the patient should know.

This field is required.

Urgency

Routine Soon (within 2 weeks) Urgent (days)

Attach records / x-rays (optional)

JPG, PNG or PDF, max 10 MB each. You can also email records to info@dentistryatmanotick.ca or fax (613) 491-7700.

Please attach a valid file.

Your answers save automatically on this device — you can safely leave and come back.

Your privacy matters: information submitted through this form is used only to provide your dental care and is handled in accordance with our Privacy Policy. For anything urgent, call (613) 491-3300.

Referral Form

Referring office

Patient & reason for referral

Referral Received